Healthcare Provider Details

I. General information

NPI: 1376260638
Provider Name (Legal Business Name): JAMIE LOU BAXTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5108 N MAIDSTONE WAY
BOISE ID
83713-1367
US

IV. Provider business mailing address

10503 W K BAR T DR
BOISE ID
83709-2449
US

V. Phone/Fax

Practice location:
  • Phone: 208-577-8672
  • Fax: 208-209-6058
Mailing address:
  • Phone: 503-407-2693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number54678
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: